10.04 Finger or toenail avulsion

Presentation

The patient may have had a blow to the nail; the nail may
have been torn away by a fan blade or other piece of
machinery; or a long hard toenail may have caught on a loop
of a shag carpet or other fixed object and been pulled off
the nailbed. The nail may be completely avulsed, partially held in
place by the nail folds, or adhering only to the distal nail
bed. On occasion, an exposed nailbed will have a pearly
appearance with minimal bleeding making it seem as if the
nail is still in place when actually it has been completely
avulsed.

What to do:

Obtain x rays if there was any crushing or high velocity
shearing force involved.

Cleanse the nailbed with normal saline and remove any
loose cuticular debris. Although it is acceptable simply
to cover the nailbed with a non-adherent dressing, the
patient is usually more comfortable with a clean nail or
surrogate in place while a new nail grows in. No dressing is truely non-adherent over an exposed naibed. If the nail or artificial stent is not used, then bring the patient back for an early dressing change in one day to prevent adherence.

If the nail is still tenuously attached, remove it by
separating it from the nailfold using a hemostat. Cleanse
the nail thoroughly with normal saline, cut away the
distal free edge of the nail and remove only loose cuticular
debris.

Inspect the nailbed for lacerations and if present carefully reapproximate with fine (6-0 or 7-0) absorbable sutures.

Reduce any displaced or angulated fractures of the distal phalynx. If a stable reduction cannot be obtained, consult an orthopedic surgeon for possible pinning.

Reinsert the nail under the eponychium and apply a fingertip dressing.

If the nail does not fit tightly under the eponychium, it can be sutured in place at its base.

If the nail is missing, badly damaged or contaminated,
replace it with a substitute. An artificial nail can be
cut out of the sterile aluminum foil found in a suture
pack or can be cut from a sheet of vaseline gauze. Insert
this stent under the eponychium as you would the nail and
apply a fingertip dressing after it is in place.

Leave these stents in place until the nailbed hardens and
the stent separates spontaneously.

Dressings should be changed every three to five days.

If the wound was contaminated, tissue macerated, pr patient immunocompromised, prescribe three or four days of a first generation cephalosporin as prophylaxis. Fractures of the distal phalynx do not always require antibiotics however.

What not to do:

Do not dress an exposed nailbed with an ordinary gauze
dressing. It will adhere to the nailbed and require lengthy
soaks and at times an extremely painful removal.

Do not ignore nailbed lacerations or fractures of the
distal phalanx. The new nail can become deformed or ingrown
wherever the bed is not smooth and straight.

Do not debride any portion of the nailbed, sterile matrix or germinal matrix.

Discussion:

Although the eponychium is unlikely to scar to the nailbed
unless there is infection, inflammation, or considerable
tissue damage, separating the eponychium from the nail
matrix by reinserting the nail or inserting an artificial
stent helps to prevent synechia and future nail deformities
from developing. The patient's own nail is also his most
comfortable dressing. Minimally traumatized avulsed nails can actually grow normally if carefully replaced in their proper anatomic position. A gauze stent left in the nail sulcus will be pushed out as the new nail grows. Complete regrowth of an avulsed nail usually requires four to five months at one milimeter per week.